Why Can’t We Talk About Heath Ledger’s Drug Addiction?

February 6, 2008

As a follow to my prior comments pointing out that the press reports on Heath Ledger’s death were unnecessarily devoid of neuropharmacological perspective, I’ll note that the report on the drugs found in Heath Ledger’s body after his death is now out. Abel Pharmboy has the call:

The cause of death was “acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine,” spokeswoman Ellen Borakove said in a statement.

The opiates oxycodone (OxyContinTM) and hydrocodone (VicodinTM and a host of other products) did not appear, to my knowledge, in the news that leaked out in the days following Ledger’s death. This is an interesting twist.

The Monitoring the Future survey tells us (see Volume 2, Figures 9-10b and 9-10c) that 12th graders and non-college young adults 1-4 yrs post highschool run respectable 12-month prevalence rates for nonprescription use of Oxycontin (3-5%) and Vicodin (9-11%). More on Oxycontin abuse is only a PubMed search away. And everyone knows about Brett Favre’s and Rush Limbaugh’s little problems. In short, those prescription pain killers have abuse potential and it would not be too surprising if anyone found with them on board was using them outside of legitimate medical control.
Back to our story. We’ve heard a lot in the news reports suggesting that Ledger was having trouble sleeping and was “anxious”. Hence the benzodiazepines and sleep aids. What we have not heard is that he had some chronic pain condition that might have explained a prescription for hydrocodone or oxycodone. MTV News is tepidly reporting the drug abuse angle:

Heath Ledger, who died January 22 in a New York apartment, suffered from an addiction to sleeping medication, a source close to the situation confirmed to MTV News.

and

The confirmation comes a day after several syndicated entertainment shows, including “The Insider” and “Entertainment Tonight,” quashed a video that reportedly showed Ledger talking about drugs at a Hollywood party. In the video, Ledger is seen reportedly saying, “I used to smoke five joints a day for 20 years.” AP reports that Natalie Portman and Sarah Jessica Parker, among other celebrities, pressured “ET” not to run the video.

This, naturally, brings me back to my observation that it is stupid to brush the drug abuse and drug dependence issues under the carpet if that is indeed a contributing factor. A little pot habit? Is it really necessary to suppress this? Or is there more being “quashed” here?
From US magazine we have additional backstory:

For three years, [Mother of Ledger’s daughter, Michelle] Williams was a firsthand witness to the gifted actor’s use of alcohol and drugs, including cocaine, heroin and “a variety of pills,” says a Ledger confidant.
In March 2006 – just weeks after the couple walked the Oscars red carpet and when daughter Matilda was only five months old – Williams drove Ledger to Promises Treatment Center in Malibu, California, the confidant tells Us Weekly.
Ledger refused to check in, instead swaying her with a pledge to clean up.

Interestingly, Michelle Williams’ publicist issues a denial of the “rehab” story but fails to deny the addiction part of the story.
There is a point in this situation, to determining and reporting this as a case in which an addiction to drugs led to an accidental overdose. Particularly if, as I speculated before, the accidental overdose resulted not from the combination of low doses of multiple drugs, but rather from a change in tolerance to those drugs. Either way however, it is useful to report and publicize. Dry warnings on the pill bottle not to mix with other prescription drugs are simply not as salient as “Your movie idol killed himself accidentally by combining the prescribed dose of six different drugs” (if this is what happened). The chance to communicate the fact that if you go abstinent from a chronic drug habit, you may no longer tolerate the previously desirable dose is key. Again, if this is what happened.
Why do we need to cover all of this up just because Ledger’s “condition” so to speak was drug abuse (if it was)?
Would we have the same squeamishness if he had plowed into a tree skiing, come down with cancer, suffered a highspeed motorsports accident, etc? Would it have been “Umm, yeah, he died. Not gonna tell you how or why. Now respect the family please and go away“? Heck, we probably would have less coverup if he’d died of AIDS in this post-Magic era!
We need to get past this. So that realistic impressions of what we know about the potential effects of dosing oneself with various drugs can be sunk into the public knowledge base. This is what science is for, is it not? So that people know things.
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[Update 2/7/08: Additional thoughts from Pure Pedantry and PalMD]

I see your point, but I also think there are other issues involved– the grieving family, who may not want to hear these sorts of things, fans and friends who don’t want to hear it, and a Hollywood system that doesn’t want to hear it. Of course they’re not going to want to admit any of this– because it means they probably knew about it way ahead of time and could be blamed for not stopping it.
I agree that it may help prevent future tragedies and could be an example of “framing” science as was discussed at the science blogging conference– people love celebrities, so scientists can talk about Heath Ledger’s overdose and Britney Spears’ bipolar disorder to get important issues across to them. I don’t like that means of delivering the message, but it may be the only way it works.

There is a problem in some sense with terminology, and with post-mortem psychology.
Anyone who keeps taking a mix of opiates and benzos is feeling pretty shitty or trying to get high. Either way, the effect was bad. Anyone who engages in that behavior is certainly at risk for addiction/abuse.

That certain video showed Heath talking about smoking pot 5 joints a day for 20 years, remember the video was 2 years old, Heath was 28 when he passed, so that would make Heath 6 years old when he started smoking pot. Since he was supposed to be at this party with a lot of high-profile people around, he could have just been bragging like other people do. He probably didn’t do anything that most other people don’t do that’s in that kind of business.
I’m one of Heath’s biggest fans, so nothing will ever take away my love & admiration for him. I was devasted when I found out that he had died, I cried for a week, so I know how hard it is on his family & friends. I just wish that everyone would back off & let his family mourn in PEACE. Everyone needs to realize that all this TRASH that’s being tossed around for all of us to read is going to effect little Matilda Rose one of these days. Right now she may be only 2 years old but believe me, she will remember back to that age. I know from my own personal experience of being raised by alcoholic parents & a family member sexually abusing me before I was 9 years old. The older you get the more you can remember & I hate it. I have taken 4 out of 6 of those meds that were mentioned, so that could have easily have happened to me.
Remember that others use drugs too, not just Heath! PLEASE LET HEATH REST IN PEACE & PRAY FOR MATILDA!!!!!

Truthfully, Ledger aside, I’m very surprised the statistics for teen use of nonprescription drugs is that low. Referring to the topic, I’ve heard friends say that they no longer need a drug dealer to get high, everything they need is right in the medicine cabinet at home.
If anyone can remember getting their wisdom teeth out, the pain killers they normally give out are going for $20 a pill on college campuses.
I completely agree that Ledger’s death should be used to stop more of this from happening, not so much for all of the Hollywood personages who are going to do it anyway, but to the millions of teens (and older) who could end up in the same situation. Of course Ledger’s death should be respected, but we might be passing on an opportunity that may not come up again until the next curtain falls before the show’s over.

Some of the sources you cite in your blog can hardly be considered reliable. How much conjecture, how much truth & how much outright untruth there is in this case none of us can say. Your confidence in pointing to an addiction to hydrocodone and oxycodone should be a great deal less than it is now. These meds are by prescription only unless bought on the street & the pills in question were prescribed. A better question than any you raise is how his physician(s) were willing to prescribe 3 anti-anxiety medications (very much a no-no, medications to be cautious with because of possible addiction, not to mention the fact that 3 of them at the same time would be poor medical practice). These 3 in addition to the ‘codone medications, also prescription meds. Only Heath Ledger knew the true story of any possible addiction & he is no longer here to tell us. That should end the discussion, unless a physician can be identified who can be compelled to explain the number, kinds & combinations of medications, & whether or not the patient was sufficiently educated by the physician about the risks associated with taking & mixing these drugs … how many, in what quantity, under what circumstances to take them, & a schedule for taking them in order to insure the safety of the patient. Education is, after all, a responsibility & obligation of the prescribing physician. As to whether Ledger was drug shopping among several physicians or not only the people now in possession of the bottles know. In the latter case, we’re still is short of being able to do more than loosely speculate that Ledger might have become addicted to 1, 2, 3, 4 or 5 of them. There is also the possibility of synergistic effects and of paradoxical reactions as well. I leave it to those who are more qualified than either of us to conclude from the evidence which of these possibilities may be true. Still we’re left knowing that Heath Ledger is the only one who could have told us most of what we have wanted to know & we can hear only silence from his grave.

“Truthfully, Ledger aside, I’m very surprised the statistics for teen use of nonprescription [use of prescription?-Ed] drugs is that low. “
Jarret do keep in mind that these are US national survey data which attempt to reflect the whole population (you can delve into the sampling methods if you read the full report). There are some sub-analyses based on certain groupings if you are interested. The point being that undoubtedly particular strata have higher rates and others have lower rates of use for a given drug. I will also say that there are scientific critiques levied that samples such as the ones used by MtF, the Household Survey, etc undercount such critical populations as homeless/street youth…and then there is the Justice system. I don’t know if that is sampled in this particular survey although I assume not.

Man, if you really want to get sick about how the public views the disease of substance dependence once a new outlet does discuss it, take a look at the WSJ Health Blog’s comment thread on this story.

We need to get past this. So that realistic impressions of what we know about the potential effects of dosing oneself with various drugs can be sunk into the public knowledge base. This is what science is for, is it not? So that people know things.

All of the “additional background story” in this case seems to be coming from “a Ledger confidant” and “an unnamed source” and other such reputable people. I’m sure these noble folks are just trying to spread the word about the dangers of drug addiction and not cynically cashing in on a chance to see their anonymity in print.
Heath Ledger died after taking a truly stupid combination of medications. That is the only thing known for certain and it is surely cautionary enough. That drug combination isn’t safer for someone who isn’t an addict is it? Drug dangers and drug problems are not limited to the addict population.

Emily, Sonetto, et alia:
You emphasize one key point for me. Why is it necessarily so objectionable to ask about the question of drug abuse? Why are Ledger’s family and colleagues so gun-shy about GoingThere?
Ask yourself this- Would you be so defensive if it was known he had “cancer” and people wanted to know what kind? If he’d been in a vehicle wreck and people wanted to know if he was wearing a seatbelt, driving too fast, hit by some random jerk who was driving too fast, under the influence, etc? Stunting a moto or just blindsided by Left-turn Louie?
You exhibit this reflexive cant that there is something “wrong” with drug abuse in the sense that it is the victim’s “own fault” and therefore we shouldn’t have sympathy. Truth is a more complicated picture of course. And there is another whole series in here about the fact that avoiding addiction is probably a lot easier, genetically speaking, for some than others. To examine the “your own fault” idea would actually be a positive thing too.

Man, I just don�t know where to begin.
I hadn’t realized I was defensive. You probably hadn’t realized that this paragraph

You exhibit this reflexive cant that there is something “wrong” with drug abuse in the sense that it is the victim’s “own fault” and therefore we shouldn’t have sympathy. Truth is a more complicated picture of course. And there is another whole series in here about the fact that avoiding addiction is probably a lot easier, genetically speaking, for some than others. To examine the “your own fault” idea would actually be a positive thing too.

is pretty condescending.
In my opinion, we can’t talk about Heath Ledger’s drug addiction right now because we don’t have enough evidence to know that it existed. No, I don’t consider anonymous tips to US Weekly to be credible sources. Last week it was rumors that he committed suicide.
In answer to your question

Why is it necessarily so objectionable to ask about the question of drug abuse? Why are Ledger’s family and colleagues so gun-shy about GoingThere?

I think what is happening is that when someone dies unexpectedly people look for ways that death could have been prevented so they can point to the ways they won’t fall to the same fate. In this country drug abuse=addict=�it�s only a matter of time.� That is pretty much the lesson I got in DARE all those years back, and it was truly shocking to me to encounter people who used illegal drugs without taking a one-way ride to the gutter.
I think labeling Ledger an addict plays into that same dynamic and serves to obscure the dangers of drug abuse. Maybe he was, and I think we�ll hear about that eventually and from sources that let their names be printed. But maybe he wasn�t. Maybe he was a more casual, weekend abuser. By all means let�s talk about the fact that prescription medications can be addictive and dangerous. Let�s talk about the dangers of drug interactions, making sure your doctor knows about all the medications you�re on, and not combining drugs to double your fun. Heath Ledger is a perfect way to start that conversation, but I�m afraid if you label him an addict, all those other casual weekend users will take that as an excuse to ignore the lesson.

Emily, first, you might enjoy this post I wrote some time ago. One of my big problems with the “one way trip” thing is outlined here.

My difficulty is that when teenagers catch you in the lies-to-children you tend to lose credibility. Thus, if they figure out you are lying before you update the lies-to-children to lies-to-adolescents or lies-to-non-scientific-audiences, you may have lost your opportunity to do so.

Back to Ledger, while I don’t think I’m “labeling him an addict” I don’t necessarily have any problem with anyone who does, precisely because it doesn’t have the silly moral connotations that you reflect, even if this is not your belief or intent. As you say, it is a good way to start the conversation about the real issues.

I didn’t mean to imply that you subscribe to the one-way trip theory of drug use. Unfortunately a lot of people in this country do. I don’t think you can simply say addiction doesn’t have any moral connotations, because it does for many people. Personally, I think it would be better to take the moral element out of the equation and talk about it as a matter of risk and risk management.
But going back to your main post, I’m not sure what you’re looking for. Are you wanting his family to come out with a discussion of his drug habits, which they may not know? Or do you want the news to discuss those habits?

Maybe we can’t talk about it because we don’t know the extent of it. You admit that you are engaging and a fair amount of speculation, and while it may be highly educated and a great teachable moment and all that, it still looks like a higher class of dead celebrity rubbernecking. No doubt a single doc should not have prescribed three ‘pams’ and two ‘codones’ but until you know more about where the scrips came from, you don’t look particularly authoritative, but something else not so flattering.
And I agree with Emily that it might be more appropriate to take this discussion to a more abstract level.

As long as we treat addicts as if they were evil puppy-eating space aliens, these things are going to get glossed over or drowned in euphemisms. In reality, of course, an addict can be the kid next door or the boss’s wife or your favorite cousin. People sometimes get stranded on that road when they start self-medicating with alcohol or street drugs while dealing with undiagnosed depression or anxiety. And a famous actor with lots of money can pay for multiple prescriptions from multiple doctors without having to deal with an insurance company. (That’s not even taking into account all the idiotic hangers-on who are always ready to party with celebrities, even when the “party” involves potentially lethal behavior.)
What happened to Heath Ledger was terrible, and very sad. It was, for the most part, his own fault, but it should be more an occasion for pity than for demonization. His family and friends have to be as devastated as any of us would be if it were our brother or best friend who had died much too young from a drug-related misadventure. Maybe it would have some benefits if Heath Ledger’s parents made his story a public cautionary tale about addiction, but right now they’re people who have lost their son, and one hopes that the public will cut them some slack.

I completely agree, DM. I am a teacher at a school that has seen two “oxy”-related deaths in the past 1.5 years. I was heartened on Friday when a student enthusiastically told me that she and her older sister were both getting long-overdue treatment for their addictions. However, I know that the use of the drug is still widespread and will continue to be as long as it is so easily accessible. Kids get around OxyContin’s “anti-abuse technology” easily by simply crushing the pills. I have a question that I am hoping you can answer: Are there any safer pain-management alternatives in the pipeline?

Science??? You base your info and ideas on an article in US magazine??? LMAO!!!! Its all gossip! Use your brain.If Mr.Ledger had been in rehab and had had a terrible drug problem then we would have heard about it BEFORE he died. There is nothing anywhere written back then.Its all after,like the doctored up fake video.You did not print all of the coroners report.He was taking the medications AS PRESCRIBED.They were found at low doses in his system.It was not the amounts that killed him. What addict follows the directions and gets his meds legally? No one is talking about the drug problem because there was never a drug problem.Heath had health issues that were and will remain private. They have never been made public because its none of anyones business.Health issues,insomnia and a pneumonia are what killed him.He made a mistake with his medications.That is what should be talked about.How easy it is to accidentally combine our medication.Thousands end up at the ER every year due to medication mix-ups.Its easier to trash him,because then we don’t have to look at ourselves. Lets learn from this awful tragedy,and remember Heath for how he lived,not how he died. RIP Heath, my friend. I miss ya mate.